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Soft skills for personal development of the surgeon for improved outcomes for patient and surgeon

2023; Medknow; Volume: 14; Issue: 2 Linguagem: Inglês

10.4103/njms.njms_103_23

2229-3418

Vyomesh Bhatt,

Innovations in Medical Education

I am honored to receive an invitation from the National Journal of Maxillofacial Surgery (NJMS) team to write this piece for its readers. Having considered several focus topics affecting the surgical fields including our unique specialty, I struggled to find one that would suitably stimulate the readership—especially from a technical and evidence perspective, one that has not already been discussed ad nauseam in the many forums and the wide-ranging literature we all can access. I chose to look back through my own journey from India—training through three states before moving to the United Kingdom and pursuing the goal of becoming a dually qualified comprehensively trained consultant oral and maxillofacial surgeon. I contemplated which aspects of my wide training over two continents and three countries I could discuss here that might give the current trainees and even trained colleagues some food for thought. Below is a short list of concepts and tools that I have gathered over the years and that I found I was not familiar with in the hierarchical training culture in India; tools and skills that I believe would benefit every individual should be incorporated into the portfolio of every trainee, trainer, unit, service, and organization for the betterment of the specialty and ourselves as surgeons, caregivers, and interacting humans. REFLECTION AND REFLECTIVE LEARNING We are a very busy group of people, and it can be difficult to stop and reflect on activities and outcomes continually. Reflection is, however, an integral part of development as a trainee and continued growth as a practicing surgeon. The execution of a surgical procedure requires precise coordination of several activities including the actual performance of the operation flawlessly with the ability to improvise when faced with an alternative situation from what was planned. It is therefore crucial when a wide multitude of factors are involved, to reflect on what went well, what could have been done better, and what must not happen again, to improve the quality of care and therefore the outcomes for future patients. As surgeons, we will all recall a particular routine operation that we wish we could have discussed for a better outcome. Our knowledge is growing logarithmically as are the requisite additional surgical skills so we cannot rely merely on what we learned in training to continue to subsist our personal development throughout our years in practice. Reflection is not reserved only for when things go wrong; it is as important to undertake when things have gone well, to find ways of improving efficiency and outcome. Reflections should be on the action after it has occurred and in action while the action is ongoing. The reflective process may be applied to every aspect of our learning and education. It helps the learner move from one experience to the next, armed with additional knowledge that will help them with the new experience. Mentorship and peer review This reflective process is reinforced when shared with others, in discussion with a mentor or peers. It can help to reaffirm the ideas that they agree with. Moreover, they may offer new perspectives or their own experiences in certain instances. Sharing reflective thoughts with others can reinforce reflective practice, because the surgeon feels accountable to the group, which promotes engagement in reflection. Peer review is a very powerful tool. It allows an independent review of what might have been influenced by the performer's own attitudes and emotions that could have influenced their thoughts and actions. For example, a surgeon who is passionate about a certain procedure is more likely to prescribe that procedure without considering the benefits of alternatives. The peer-review process helps surgeons realize their preference and consider the options that would be more effective for the patient. I can recall an episode from my career when I considered my orthognathic operative procedure fairly efficient and invited one of my surgical colleagues to come and observe me undertake the operation from start to finish. I expected to be told how everything was simply perfect only to be shocked at receiving two A4 sides of observations and suggestions to improve efficacy. It opened my eyes to how tunneled I was in some of my thoughts and processes. It is now routine in my practice to invite colleagues to observe and comment. We learn from the observations to improve and where commended we have known those colleagues to take it away to their own practice—it works both ways—we have all learned collectively and improved together. BRIEFING AND DEBRIEFING Briefing The advent of the World Health Organization (WHO) Surgical Safety Checklist and its adoption by most healthcare organizations as part of any intervention has made significant inroads into the reduction in avoidable mishaps in the operating room by discussing every procedure at a preoperative briefing with all staff involved in the procedure present and fully engaged, and the checklist is followed in accordance with the guidance outlined and every step is discussed for patient factors, resources including tools and equipment, personnel, ergonomics, and human factors with a clear and precise delegation of duties so that all in the room know what to expect when, what their role is in the event of the routine, and if things went outside of the routine. Debriefing, which should be required in every operating room, is not necessarily restricted to negative experiences. These exercises should also focus on what went well. For example, a surgeon performing a bilateral sagittal split operation had a smooth conduct of the surgical procedure in record time. At the end of the procedure, the surgeons should reflect and assess all of the processes that worked well. These factors may include the nurses setting up the equipment tray with all the necessary equipment, appropriate preoperative planning to ensure sequential, meticulous execution of the various steps of the osteotomy, and prudence of the anesthetist in inducing the patient and waking the patient smoothly from anesthesia without significant changes in blood pressure along with adequate time allowance for the infiltration of local anesthesia and any additive tumescent solution to work and appropriately timed breaks for hydration and comfort. Sharing these reflections with coworkers not only highlights particularly effective methods, but also positively reinforces good habits in the operating room and boosts morale. A growth mindset A belief system that embraces challenges as opportunities has a positive attitude to learning and recognizes that considerable effort is required in the path to mastery and that talent can always be improved, always stepping out of the comfort zone and accepts that mistakes will occur but analyzes those mistakes to learn from them, to grow as an individual and shares the learning so everyone learns. The individual and team focus on the process rather than the outcome, receive constructive feedback, whether positive or negative, implement a marginal gain attitude to improvement, and are inspired by others' success and not threatened by it. The term growth mindset was coined by American Psychologist Professor Carol Dweck in her 2006 book Mindset: The New Psychology of Success. I am a great fan of the former captain of the Indian cricket team and current chief of the Chennai Super Kings, MS Dhoni, the veritable "Thala." In his many interviews that I have followed, I have always been inspired by his ability to think calmly even in the tensest situations. His approach is to always take care of the processes, the controllable components as he likes to call them, and not focus on the outcomes and results. If the small subprocesses of the whole activity are independently practiced and honed to efficiency, the marginal gains from each of these will cumulatively contribute to the overall performance of the team and the result will reflect the efforts. BLACK BOX THINKING Every experience is analyzed like the information from an airplane black box and cockpit voice recorder (CVR) to arrive at the root cause of any occurrence, and learning to share for everyone's benefit is derived. This concept incorporates and brings together several of the tools and concepts already mentioned above. It is inspired by the approach to any mishap or incident in the aviation industry and how the information from the crew is analyzed against that from the black box and CVR to arrive at the root cause of the incident and publish the system, machine, and human failures for everyone to learn in what is termed a "just culture" where the perpetrator of the errors is not penalized but trained further so the error does not recur and all the learning is shared. Even near misses are reported and discussed. There is a 1 in a million chance of a person being harmed while traveling by plane [Figure 1]. In comparison, there is a 1 in 300 chance of a patient being harmed during health care. In Table 1 are some reasons to compare the aviation industry with healthcare.Figure 1: Fatality rate in the US Army aviation industryTable 1: Why should there be a comparison between aviation and surgery?For an accident to occur, usually several steps must fail and several contributors go unchecked, as seen in Figure 2, where the holes in the Swiss cheese line up for something to slip through any defense, barriers, or safeguards.Figure 2: Swiss cheese model of accident causationThere are now systems in place for recording near misses and errors and even investigations of any "never event" in health care. The introduction of lists and checklists to improve safety and prevent mishaps has sometimes been seen as an additional bureaucracy rather than a safety measure because of the culture. If a mistake were to occur and it is documented, now there is the concept of the "duty of candour" where the patient is informed of the occurrence and the outcome of any investigation including measures put in place to prevent future recurrences and the information is shared across the organization for learning by the whole system. Formerly, these would go unreported, which meant not only was the patient left in the dark but no one else learned from the incident to prevent its recurrence. In health care, like in aviation before 1977 following the Tenerife air disaster when two 747 Boeings collided on a runway killing all 583 passengers and crew, there existed a steep vertical hierarchy. The captain was the leader and the team was subservient and would be reluctant to question any decisions. What came out of the disaster [Figure 3] was a completely new independent system of reporting near misses and accidents with full disclosure to all, with the intent to learn from an occurrence and avoid the same mistakes in the future. In health care too, the surgeon is the maximum leader whose decisions would rarely be questioned in the past and a reluctance to interrupt from anyone else in the theater environment. While leadership in executing the surgical process is vital since the buck stops with the surgeon, the absence of two-way communication can result in a tunneling of focus while ignoring changes in other influencing factors that could potentially influence the process and outcome, in other words losing situational awareness. This is even more so in the emergency situation when we are all prone to the "amygdala trap" where primitive processes take over the brain in the execution of the fight or flight response. In this situation, it is crucial to have a more horizontal hierarchy, a concept termed cockpit or crew resource management (CRM) [Table 2]. This allows an information feedback loop by effective communication from any source to improve the situational awareness of the entire team and therefore improve preparedness in a dynamic situation and improved safety for the patient and the team and a better outcome.Figure 3: The outcome of the Tenerife disaster was a universal system of reportingTable 2: Cockpit or crew resource managementAs a trained pilot (Private Pilot License), I have always tried to incorporate the safety culture from my aviation world into the surgical world. I make it a point to prep for lists in advance and on the day do checks before, during, and after an operation to ensure we have followed the plan for the procedure, which was laid out before the operation or the whole team to be familiar with. I have empowered every member of the team to query any deviations from the plan and we have introduced the concept of "ten thousand feet in theatre"—where anyone in the operating room is able to say this phrase to draw attention and engage the rest of the team to a crucial piece of information—based on the airline concept of no unnecessary chatter when the aircraft is in flight between ground and ten thousand feet. We have also process mapped our procedures and broken up component parts of the patients' perioperative experience into the preoperative and anesthetic phase, the intraoperative phase with each step and stage separately defined and then the recovery and aftercare phase with the aim to review these ritually to see where we could improve efficiency in terms of timing, patient experience, and team experience and morale. We collect patient-related outcome measures (PROMS) data from satisfaction questionnaires that we continually improve based on feedback received. Our team not only records when things were less than ideal, but also records when everything has gone well, on a hospital app called GREAT-ix—to record what was great. The app generates a congratulatory email for all members of the team for a job well done, and they can use it in their appraisals. We have a record of zero (0) late runs of over 10 minutes from the end of operation time allotted in 11 years, 98 percent satisfaction of the patient's reported outcomes related to the perioperative phase of their journey, and a 100% record of discharge for all elective cases within 23 hours of the operation. The orthognathic service has been commended as the most efficient in the UK for the volume performed by a single surgeon (between 30 and 50 per year) by Get It Right First Time (GIRFT), a national program designed to improve the treatment and care of patients through an in-depth review of services. I would like to include here seven lessons to learn from airline safety that would help improve the safety record of any surgical team. Require communication skills training for all healthcare personnel credentialing to work as a team and introduce and ingrain the concept of flat hierarchy. Institute a briefing before all procedures detailing steps and expected issues and procedures to adopt in eventualities. A debrief at the end of every procedure to analyze against this initial briefing and an agreement to record what went well and what can be improved. Standard operating procedures (SOP)—agreed for every operation and process map each procedure to analyze and then put in measures to improve efficacy and analyze and if successful incorporate into the SOP. Recognize fatigue and age as factors in performance—include medical fitness—pilots have health checks every 6 months. Include surgical "check rides" as a condition of credentialing—peers observing each other in a nonthreatening environment. Morbidity and mortality conferences should be modeled on investigations of aviation accidents; no blame; look for root cause. Institute random drug testing of all operating room staff—controversial—15% of all physicians will, at some point in their career, become temporarily impaired by drug, alcohol, psychiatric, or other problems.(Boisaubin EV et al. Identifying and Assisting the Impaired Physician Am J Med Sci 2001;322:31-36). Lastly, before I conclude I would like to focus (see point 4 above) on ergonomics and human factors and their importance in aptitude, attitudes, behaviors, and performance in the operating room environment. Ergonomics is defined as the technology concerned to optimize the relationships between people and their activities by the systematic application of the human sciences, integrated within a framework of system engineering, and understanding of interactions among humans and other elements of a system. In this context are listed some of the characteristics of leaders of a high-performance team such as a surgeon [Table 3].Table 3: Leaders of high-performance teams (surgeons) should possessThe optimum performance of a surgical team will be influenced by the human factors affecting every member of the team including their physiology and how well they are, their psyche in the moment, their interpersonal relationships, the environment in surroundings, and of course the proper functioning of equipment and technology. An acknowledgment of these factors will contribute to better situational awareness. Figures 4-6 indicate how personal human factors may influence the performance of the team and the outcomes. In our theater, we discuss all of these in the briefing and empower the team to raise any concerns at the outset or as they develop so we can as a team find appropriate mitigation. Simple measures such as insisting on one runner to record hourly breaks for hydration or comfort have raised the focus bar in the operating room.Figure 4: Relationship of workload with performance and the role of human factorsFigure 5: Situational awareness can be affected by a vertical authority gradient and requires mental models createdFigure 6: HALT bucket self-assessment before commencing any surgical activityIn conclusion, anxiety never disappears in a human being, be it in an airplane or operating room; it merely remains dormant when there is no cause to arouse it. Our challenge is to keep it dormant. I hope in my small way I have aroused reflective moments in all the readers, and if so, the objective of this editorial is achieved. Everything else is garnish….